BP-83289RESIDENTIAL ❑ Phased Approval (R106.3.3) w
$25.00 APPLI[CAT)ION FEE IS NON BE -FUNDABLE & NON-THATSFER I,E 'a,J
DATE RECEIVED x �,
DARTMOUTH BUILDING DEPARTMENT
400 Slocum Road VIA
z Dartmouth, MA 02747
A:
Rhone: 508-910-1820 Fax: 508-910-1838 '*
www.town.dartmouth.ma.us
APPLICATION TO CONSTRUCT, REPAIR, RENOVATE OR DEMOLISH A ONE OR TWO FAMILY DWELLING
THIS SEC ICON NR OFFICIAL USE ONLY, - ,
RI=GEt1�ED BY BUILDING PERMITNU E
DATE]SSUED. ,
r
®
0 7 201
SIGI1tATlJRE.
DATE:
Building Commissioner/Irispecforof Buildings
Zonrng Disfrrct K;�
roposecl Use Zone t�X C! B
Aquifer Zono
TNE_FOL OWING AGENCIES SI-IUULD BE NOTIFIED. `'
DPW
Board of ❑Board of O Cons. n Planning
0 Address
❑Engineering
D Cross
Appeals 46alti
Commission
Card
co
t] Fire ❑Gas
❑ Etectnc i3 Other'
❑WaferCairJ `
❑ Sewer Card
Chief -:- Cut Off
Cut Off
_ Cut_Off ,
Cuf;Off
DEPARTMENTAL APPf;COVAL'(S) _
Board of Health:
Signature:
Date:
Conservation Commission:
Signature:
Date:
D.P.W.:
Signature:
Date:
Fire Chief:
Signature:
Date:
Other:
Signature:
Date:
Brief description of work being performed;
11.1 Property Address
T of
Contact PersonAj_b/W' V�t
Phone Number: /7�4 n
1.4 Water Supply (MGL c40 s54): 1.5 Sewage Disposal System:
❑ Municipal ❑ Municipal
Private Well )�On Site Disposal System
1.2 Assessors Map & Lot Number:
Map Lot -
1.3 Historical District ❑ Yes No
Year Builtl4c2
❑ Altering more than 25% per side of building
Has application been submitted to the Historic Commission?
❑ Yes ❑ No Date:
5 /13
0 CONSTRUCTION PLANS El SITE PLAN ❑ENERGY REPORT
RESIDENTIAL
Item I Estimated Cost ($) to be completed by permit applicant
2.1 Owner Record: ��i
�/
Name (print)
2.2 Authorized
Name (print)
76—d 6 A � z �!-dJ
Contact Address Phone Number
Contact Address
Phone Number
3.1 Licensed Construction Supervisor/SpecialtyLicense: C°' S c n t(1534,u ��4 d
� I'O C) Licens Number
Company Name/Contractor Name: /jj S' o
11
Address: e C) V QC' rr C 41/� S �� So Expiration Date:
Signature: Telephone: "S ��r%3� -- ��
3.2 Homeowner Exemption - One & Two Family Only Section 110.135.1.3.1 Exception:
FOR HOMEOWNERS WHO INTEND TO PERFORM AND BE RESPONSIBLE FOR THEIR OWN PROJECT
Exception: Any Homeowner performing work for which a Building Permit is required shall be exempt from the provisions of this section; provides that if a Homeowner
engages a person(s) for hire to do such work, that such Homeowner shall act as supervisor.
For the purposes of this section only, a "Homeowner" is defined as follows: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which
there is, or is intended to be, a one or two family dwelling, attached or detached structures accessory to such use and/or farm structures: A person who constructs more than
one home in a two-year period shall not be considered a Homeowner.
If you are applying under this section sign below:
Signature:
Worker's Compensation Insurance Affidavit must be completed and submitted with this application. Failure to provide this
affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached: ❑ Yes ❑ No
=: ,: _ , ,._-SE6-TIC31� S. t}ESCRtP-.TfON-OF PROP'C)SEEfl11FORK;�Chect��'!f appficable}" �.� � �-
❑ Deck ❑ Pool ❑ Repairs ❑ Alteration ❑ Chimney/Fireplace ❑ Woodstove/Pellet Stove
❑ New Construction* ❑ Accessory Bldg. ❑ Addition ❑ Roofing/Siding ❑ Replacement window/door
(Energy report required) (Shed/Garage) (Energy report required) No. of windows Doors
❑ DEMOLITION (specify):
Location of debris removal (per MGL C.40 Sec 54):
Facility Name:
*If new construction, please complete the following:
Single Family: No. of Bedrooms
❑ Dumpster on site ❑ Dumpster On Street
Location:
No. of Baths
Two Family: No of Bedrooms Unit 1 No. of Baths Unit 1
No of Bedrooms Unit 2 No. of Baths Unit 2
❑ Furnace (hot air) - fuel gas (natural or propane), fuel oil, electricity, other (specify): _
❑ Boiler (heating) - fuel gas (natural or propane), fuel oil, electricity, other (specify): —
❑ HVAC (combined unit) - primary fuel, natural gas, propane, electricity, other (specify):
❑ Air conditioning - (separate unit)
❑ None of the above to be provided
❑ Hot Water: Gas Electric Fuel Oil
Other
1. Building
2. Electrical
3. Plumbing
4. Mechanical (HVAC)
5. Total=(1+2+3+4
.;t[vve_cvinptetea:wttert vwrrGr a_ayat,u vf__vuru�nve�r=9l�prtra. ter uu�tu�rtgpermiif
(Ple e Print)?T�
as Owner of the subject property hereby authorize
to act on my ehalf,iin, all matters relative to work authorized by this building permit application.
Signature aYow- ner Date IV
SECT[ON>76 - OWNER AUTHORIZED AGENT;DECLA"TION ,
as Owner/Authorized Agent hereby declare that the statements and information
on the forego' g ap ication are true and accurate, to the best of my knowledge and belief.
Signed under the pains and penalties of perjury.
41
Signature of_94-ner/Xjthodzed Agent Da e
I Less Application Fee: $25.00 I Remaining Balance: $
Total Permit Fee: $ )7
Other $ Amount $
Gross Area - New Construction total sq. ft. gy
Gross Area - Alteration total sq. ft.
Permit Issued to:
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